This timely filing appeal letter template can be tailored to fit your denial. For assistance with a completely researched, focused and custom letter, call the helpline @ 920.664.9407.

Provider

[ADDRESS]

[Date]

[Health Plan]

[Address]

[City, State, Zip]

Subscriber No: [Number]

Patient Name: [name]

To Whom It May Concern:

I am writing to you in regards to a claim submitted by [Medical Provider] for [patient]. The charges were rendered on [Date of Service] and totaled [Claim dollar total]. [Health Plan] has denied payment for these charges because [Health Plan] has indicated that these claims were not processed due to their failure to meet the applicable timely claim filing requirement.

I had applied for eligibility through my employer, but unfortunately I was not notified of my coverage until later. If I had known that I was eligible at the time of service, I would have provided this to [Medical Provider] without hesitation. I am requesting a one time exception for [Health Plan] to pay this claim as I am an eligible subscriber of the plan and feel I should not be penalized for someone else’s error.

This is a claim for a medically necessary service and I am requesting that you reconsider your denial of this claim and process the claim for payment. If you have any questions, please do not hesitate to contact me at (---) --- ----. Your cooperation and consideration is anticipated and greatly appreciated.